Community Client-Led ART Delivery Model (CCLAD)

Transcription

1 Community Client-Led ART Delivery Model (CCLAD)

2 Contents Background... 3 Aim... 6 Objectives... 6 The Community Client-Led ART delivery (CCLAD) model by TASO... Error! Bookmark not defined. Description of CCLAD... 6 Eligibility for CCLAD... 6 Packaging and delivery of ARV drugs... 7 The Community Client Led ART Delivery model... 9 The setting for CCLAD... Error! Bookmark not defined. Resources required... 9 Capacity building for implementation of the CCLAD model Who qualifies to be a CCLAD leader? Role of service providers Data Management Monitoring of clients on ART Risk management measures Number of clients to be served under this model Implementation Plan... Error! Bookmark not defined. References... Error! Bookmark not defined. 2

3 Abbreviations ART PSG FAP TASO PEPFAR HBAC CDDP VSLA SRH HB NACS HCG HCT TB OIs ICF GBV MUAC VDRL TPHA LFTs RFTs MoH HIV AIDS BCC PHDP RRC Antiretroviral Therapy Peer Support Group Facility ART Point The AIDS Support Organization Presidential Emergency for AIDS Relief Home Based HIV/AIDS Care Community Drug Distribution Point Village Savings and Loan Associations Sexual and Reproductive Health Haemoglobin Nutrition Assessment, Counseling and Support Human chorionic gonadotropin HIV Counseling and Testing Tuberculosis Opportunistic Infections Intensified Case Finding Gender Based Violence Mid Upper Arm Circumference Venereal Disease Research Laboratory test Treponema pallidum hemagluttin antigen Liver Function Tests Renal Function Tests Ministry of Health Human Immunodeficiency Virus Acquired Immunodeficiency Syndrome Behavioural Change Communication Prevention Health Dignity Positive health Risk Reduction Counseling 3

4 Operational Definitions The C o m m u n i t y D r u g D i s t r i b u t i o n P o i n t Model (CDDP); is a n e v a l u a t i o n a n d delivery model for Antiretroviral Therapy (ART) in which patients participate in their ART care at a the community Peer Support Group (PSG) Leader; is an expert client, experienced in ART, with an excellent adherence record and has been trained to provide basic psychosocial support to fellow clients. Stable Client; this is a client who has been on ART for at least 1 year with a suppressed viral load and does not have any active stage 3 or 4 Opportunistic Infections (OIs) 4

5 Background The AIDS Support Organization (TASO) started a free Anti-Retroviral Therapy (ART) program in 2004 to contribute to the fulfillment of her mission that seeks to improve the quality of life of persons, families and communities infected or affected by the HIV/AIDS epidemic. At inception of the program, ART delivery was home-based with a facility-based component to cater for those clients who for one reason or the other were unable to receive their drug refills at their homes. With the increasing enrolment of clients on ART, it meant that the organization had to increase human resource to be able to deliver drugs to the increasing number of clients which was not possible due to funding challenge. This scenario gave birth to the Community Drug Distribution Points (CDDP) concept. Here, clients who are stable on treatment were grouped and tasked to identify a convenient place within the community where they could receive their ARVs as a group. Clients who receive ARVs from the CDDPs are headed by a community ART support agent (CASA) who is an expert client. This client has a responsibility among others of ensuring that all his/her group members turn up at the CDDP for their refills, besides monitoring their adherence. Home deliveries by staff were maintained for clients who were stable but with disabilities. By end of 2015, TASO was caring for over 68,000 active clients on ART with 70% of them receiving drugs from the CDDPs. Each CDDP is envisaged to have not more than 60 clients receiving ART refills at that point. With the roll out of new MoH guidelines (MoH, 2014) on ART management which require test and start/treat for KPs, adolescents and children, pregnant and lactating mothers there has been continuous referrals of clients on ART to CDDPs, leading to congestion at these service points hence affecting service provider- patient ratio. (Nabwire Chimulwa et al., 2014) Additionally, challenges with monitoring adherence emerged yet recruiting more staff to manage these CDDPs was not possible due funding gaps. The introduction of ART led to improvement of quality of life of clients and therefore there was no need of them spending long hours in the clinics and CDDP. A need to shift tasks by involving expert clients became necessary to help in delivery of drugs to peers and to monitor adherence through follow-ups.(nantume, 2008) This is more sustainable since clients take on more responsibility to manage their health. The 5

6 Community Client led ART delivery (CCLAD) Model is an expansion of the Community ART delivery model with less human resource needs, use of lay persons, increased community participation and ownership using appropriate technology (e.g. use of phones for follow up and reminders). Central to the function of this model are the professional health workers and expert clients stable on ART.(Kusemererwa, Wangisi, Sebuliba, & Nkoyooyo, 2008) Aim The overall goal of CCLAD is to increase accessibility to Anti-retroviral drugs through Meaningful Involvement of PLHAs, scale up of peer adherence support in order to achieve suppressed viral load. Objectives To reduce congestion at Community Drug Distribution Points and the facility ART clinic To promote Meaningful Involvement of People living with HIV/AIDS and to enhance patients self-management Description and implementation of CCLAD This involves analyzing and mapping clients from the Community ART points in line with their villages/locations. Clients that meet the inclusion criteria are evaluated by the Clinical Services Supervisor, the counselor in charge of the CDDP and the CASA for the CDDP on how the client has been conducting him/herself at the CDDP and in the community. Those who qualify are supported to form a peer support group of 10 members that are receiving ARVs drug refills at CDDPs. The members then select their group leader who acts as expert clients, and is responsible for picking drugs from the CDDP in charge who is a full time TASO staff, dispenses the drugs to the group members at their agreed on location in the village, quarterly documents and monitors group members for ARV adherence. The CCLAD group leader collects 3 monthly ART refills from the CDDP on behalf of the peers or a designate agreed on. All group members attend their six monthly reviews and annual viral load monitoring at the mother CDDP with the rest of the clients. In cases of high viral loads and emergency of other OIs, the identified client is supported by the counselor and a peer to be up-referred and linked back to the facility. Eligibility criteria for CCLAD To be included in the model one to qualify to be part of this model; 6

7 Client should have been on ART for at least 24 months The client must be virally suppressed 1000copies/ml of blood A client should consent (signed consent form) to receive their drug refills in this model Client with no active WHO stage 3 or 4 disease. Not indulging in harmful behaviors that affect adherence (substance abuse, GBV, ) In case of switch of regimen, then client should have been on the current regimen for 6 months The model shall exclude;. Pregnant / lactating women Adolescents and children below 18years Clients that are not yet stable on ARVs i.e. unsuppressed viral load >1000 copies/ml of blood Clients on TB treatment Packaging and Labelling of ARV for each member ready for delivery Prior dispatching drugs to the CDDP, Pharmacy staff generates a drug pick list which is used to request drugs that are then availed for prepacking. TDF TDF NVP Sarah Nakato 001/12 DUO-VA NVP Moses Kato. 001/13 NVP Pre-packing of drugs for clients in the groups is done by pharmacy staff at the facility using the CCLAD group pick lists as a guide. These drugs are packed in combination form, using different methods (tied using a masking tape or packed in Zip-lock bags and clearly labeled with the clients name and Registration number) for easy identification and distribution. Where a client has 7

8 more than one packet of drugs the packets of drugs are tied/held (Fixed) together with a masking tape or in Zip lock bag and labeled. This is to ensure, that drugs of clients are not mixed up. The group member who comes to collect drugs on behalf of the group receives the following items; ARVs and septrin/dapsone, CCLAD monitoring form, Intensified TB Case Finding form (ICF), BCC form and condoms. The signed CCLAD reporting form, BCC form and the filled ICF forms shall be returned in the next 1 day to the CASA who then delivers them to the counselor in charge of the CDDP at the TASO Centre within 1-2 days for review and forwards them to the Pharmacy for entry. A transport refund is provided to the CASA who returns the accountability. The counsellor is required to update the HIV care card using information from the CCLAD pick list and ICF forms. CCLAD pick lists is used to identify those who missed picking the ARV drugs so that they are followed up according to Ministry of Health guidelines. A group of Counselors taking part in verification of packed, ensuring the right patient is packed the right ARV drug regimen community 8

9 Figure 1: The Community Client Led ART Delivery model TASO Facility Eligibility for CCLAD Client should have been on ART for at least 24 months The client must be virally suppressed 1000copies/ml A client should consent (signed consent form) to receive their drug refills in this model Client with no active WHO stage 3 or 4 disease. Not indulging in harmful behaviors that affect adherence (substance abuse e.g smoking, alcoholism, GBV, etc) Adherence of >95% in the past one year [appointment keeping and 3 day recall, pill count In case of switch of regimen, then client should have been on the current regimen for 6 months CDDP TASO Staff Forming CCLAD groups Facilitate meeting to agree on pickup points Delivery of ARVS CCLAD Groups 5-10 Clients per group Collection of User fees Facilitation to group leader Distribution of ARVs on same day Resources required The following resources are essential for the smooth running of CCLAD:- ARVs, Septrin /dapsone Carrier bags Zip-lock bags Packing materials Masking tape Markers Condoms Pick list Data collection tools- CCLAD monitoring form, BCC form, ICF, Client cards/books, Register, Community referral forms IEC materials 9

10 Directory [services] Capacity building for implementation of the CCLAD model Staff Staff are oriented on the CCLAD model and all its implementation aspects as well as the data collection tools (including pictorials on the data collection tools), ART Management, SRH, TB management, viral load monitoring, Income Generating Activities (IGAs) through VSLA, aspects of gender, and sign language CCLAD Leaders These are oriented on CCLAD model and all its implementation, basic counseling skills, data collection tools (including pictorials on the data collection tools), basics on ART Management, SRH, TB management, viral load monitoring, Income Generating Activities (IGAs) through VSLA, aspects of gender, Sign language Who qualifies to be a CCLAD leader? Role model in adherence Able to read and write Willingness to volunteer Person with high integrity Open about his/her sero status Exemplary Note: At selection of group leader s gender balance will be encouraged. When all is done to ensure quality CCLAD Leader pick their drugs to go and serve others at the agreed venue in the 10

11 Figure 2: Showing the role of each service providers Cadre Roles Counselors Clinicians (C.Os, Nurses) Pharmacy Staff CASAs Laboratory technicians M & E Drama group members Village Savings and Loan Associations(V SLA) CCLAD Leader Coordinates the CCLAD and work closely with the clients who come to pick drugs on behalf of other clients. Ensures that the client picking the drugs is the right representative of the group. Picks drugs from the Pharmacy, sign for them, and then hands them over to the group representative and ensure that he/she receives any balances of drugs and returns them to the Pharmacy. Follows up clients who missed appointment within a week after reporting. Refills ARVs, updates the ART card, offers psychosocial support, health education, monitoring, NACS, HCT, referrals provision of FP, TB screening, economic empowerment. Clinical monitoring of clients, ART refills, follow-ups, bleeding clients, prescription and dispensing (FP, STIs), clinical evaluation and referrals, health education, TB screening, NACS, Filling VL request forms Pre-pack drugs and label drugs with client s names and registration number on each packet of drugs and dosage/frequency. Routinely update the Pharmacy information system whenever they receive feedback from the counselor in charge of the CDDP about the drugs they took and whether the group received the medicines or not. Mobilizing clients for CDDP, collect reports from CCLAD leaders, home visits/ follow ups, referrals, adherence counselling, TB screening, health talks, taking anthropometric measurements Bleeding clients, Conducting HB,HCG,TPHA tests, DBS, preparing result slips for clients Orientation of the team on data collection tools, review completeness and accuracy of data captured in the community, reporting, transfer data into the ART card and ART register. Data input into the HMIS from ART card Sensitization through MDD, group sessions, Economic empowerment skits Involve external facilitators for economic empowerment talks, forming saving groups, identification of projects e.g. piggery, Tents & chair business Mobilizing PSG members, distributing drugs, Health education, peer counseling, follow up, collecting ARVs from CDDP, documentation and reporting 11

12 Data Management TASO uses the MoH data Collection and reporting tools. Under this model, a simple tool with important monthly variables will be designed to help CCLAD leaders and CASAs collect data and thereafter, the data will be transcribed to the ART register. In order to make entries timely the data collection tools should be returned to TASO the following day after distribution of the drugs. This will be a one page data collection tool with all the variables of each client on one line and signature or thumb print at the end to confirm that the client received the drugs. When this form is returned to a TASO facility this data is entered into the ART register. If the form is not returned the day when its expected, the Clinical Services Supervisor will follow up with a phone call to the person who received the drugs from the Pharmacy and if within 2 days there is no response then the Clinical Services Supervisor or the staff attached to the CDDP will be required to reach that CCLAD Leader s home to find out what happened and pick the forms but also handle the issues that caused the delay to return the forms on time. Monitoring of clients on ART There will be two levels of Monitoring; the first level of monitoring will be done by the representatives of the groups who will be able to pick some information from clients and feed in the basic indicators. These will be designed on the data collection tool. This monitoring will be done every time another client is receiving a drug refill from a group representative (CCLAD Leader) and this information will be forwarded to TASO to be captured in the registers and also electronically. This will be combined with purposive home visits by staff from TASO to those clients who are reported to have issues with adherence, not responding well to treatment and other issues as reported by the CCLAD Leaders. 12

13 CCLAD group members undergoing documentation and distribution of drugs, the Leader taking lead The second level is the 6 monthly reviews by the evaluation team. This is the time when a team of clinicians, Laboratory technicians and counselors from TASO will be scheduled to visit a CDDP and carry out clinical assessments, counseling and do Laboratory assessments that will include Viral load monitoring, HB, HCG, VDRL or TPHA, LFTs, RFTs and other Chemistry and Hematology tests as deemed necessary by the clinician. HB, HCG, VDRL or TPHA results shall be instantly given to clients and the necessary action taken, whereas viral load, LFTs, RFTs and other Chemistry and Hematology tests will be returned to the client by the Clinician/Counsellor at the next visit for the group. These tests will be analyzed at case conference and decisions made for each client depending on the outcome of the tests and observation. The decision includes but not limited to; Intensive Adherence Counseling (IAC), Purposive Home visiting, switching regimens, substituting drugs or switching a client from Community delivery model to facility model for closer and more routine monitoring. This will be clearly explained to the client. Risk management measures Group members agrees on the venue for example clients home where they will be receiving their drugs in the community and such a venue is communicated to both the CASA and the TASO staff in charge of the CDDP for close follow up on the group. Phone numbers of the group members gathered along with the members list. These is useful in verifying whether the group members received their drugs. Two days from the date of delivery of drugs the staff in charge of the CDDP shall select a phone number randomly among the group members to verify if the clients received their drugs. Once this notification is made the pharmacy system is up dated. 13

14 Number of clients to be served under this model In order to deliver quality services, and not to over load the clients but most important to reduce on the size of the risk, the maximum number of clients to receive drugs under the CCLAD model will be 10.It s envisaged that there is sufficient quantity of drugs that can be carried comfortably by an individual in a bag especially with fixed dose combinations (FDC) in place, but it s also important to spread the risk by controlling how much drugs to be given to an individual. The clients will continue to receive their drugs at the same point on the same day but each cohort with a different individual carrying and distributing the medicines. References Kusemererwa Medical Doctor, S., Wangisi, J., Sebuliba, I., & Nkoyooyo, A. (2008). Integrating ART (anti retroviral therapy) into communities - a TASO Mbale experience. XVII International AIDS Conference. 3-8 August 2008, Mexico City, Mexico. Nabwire Chimulwa, T., Kasibula, A., Kateeba, A., Bakashaba, B., Etukoit, M. B., & Nantume, S. (2014). Expanding ART delivery through a client led approach at a Ugandan NGO: pilot experiences at TASO Uganda Limited. 20th International AIDS Conference, July 20-25, 2014, Melbourne, Australia. Nantume, S. (2008). The use of expert clients in scaling up ART delivery in Communities: TASO ART community model in Uganda. XVII International AIDS Conference. 3-8 August 2008, Mexico City, Mexico. 14

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